Arthroscopic partial meniscectomy for degenerative meniscal tear

Understanding the podocyte immune responses in proteinuric kidney diseases: from pathogenesis to therapy

The glomerular filtration barrier, comprising the inner layer of capillary fenestrated endothelial cells, outermost podocytes, and the glomerular basement membrane between them, plays a pivotal role in kidney function. Podocytes, terminally differentiated epithelial cells, are challenging to regenerate once injured. They are essential for maintaining the integrity of the glomerular filtration barrier. Damage to podocytes, resulting from intrinsic or extrinsic factors, leads to proteinuria in the early stages and eventually progresses to chronic kidney disease (CKD). Immune-mediated podocyte injury is a primary pathogenic mechanism in proteinuric glomerular diseases, including minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and lupus nephritis with podocyte involvement. An extensive body of evidence indicates that podocytes not only contribute significantly to the maintenance of the glomerular filtration barrier and serve as targets of immune responses but also exhibit immune cell-like characteristics, participating in both innate and adaptive immunity. They play a pivotal role in mediating glomerular injury and represent potential therapeutic targets for CKD. This review aims to systematically elucidate the mechanisms of podocyte immune injury in various podocyte lesions and provide an overview of recent advances in podocyte immunotherapy. It offers valuable insights for a deeper understanding of the role of podocytes in proteinuric glomerular diseases, and the identification of new therapeutic targets, and has significant implications for the future clinical diagnosis and treatment of podocyte-related disorders.

Arthroscopic partial meniscectomy for the degenerative meniscus tear: a comparison of patients included in RCTs and prospective cohort studies

BACKGROUND AND PURPOSE

Concerns exist regarding the generalizability of results from randomized controlled trials (RCTs) evaluating arthroscopic partial meniscectomy (APM) to treat degenerative meniscus tears. It has been suggested that study populations are not representative of subjects selected for surgery in daily clinical practice. Therefore, we aimed to compare patients included in trials and prospective cohort studies that received APM for a degenerative meniscus tear.

PATIENTS AND METHODS

Individual participant data from 4 RCTs and 2 cohort studies undergoing APM were collected. 1,970 patients were analyzed: 605 patients included in RCTs and 1,365 included in the cohorts. We compared patient and disease characteristics, knee pain, overall knee function, and health-related quality of life at baseline between the RCT and cohort groups using standardized differences, ratios comparing the variance of continuous covariates, and graphical methods such as quantile-quantile plots, side-by-side boxplots, and non-parametric density plots.

RESULTS

Differences between RCT and the cohort were observed primarily in age (younger patients in the cohort; standardized difference: 0.32) and disease severity, with the RCT group having more severe symptoms (standardized difference: 0.38). While knee pain, overall knee function, and quality of life generally showed minimal differences between the 2 groups, it is noteworthy that the largest observed difference was in knee pain, where the cohort group scored 7 points worse (95% confidence interval 5-9, standardized difference: 0.29).

CONCLUSION

Patients in RCTs were largely representative of those in cohort studies regarding baseline scores, though variations in age and disease severity were observed. Younger patients with less severe osteoarthritis were more common in the cohort; however, trial participants still appear to be broadly representative of the target population.

The Relationship Between the Timing of Knee Osteoarthritis Diagnoses and Arthroscopic Partial Meniscectomy

BACKGROUND

There is ongoing debate regarding the efficacy of arthroscopic partial meniscectomy (APM) for meniscus tears in patients with knee osteoarthritis (OA). Some insurance payers will not authorize APM in patients with knee OA. The purpose of this study was to assess the timing of knee OA diagnoses in patients undergoing APM.

METHODS

A large commercial national claims data set containing deidentified information from October 2016 to December 2020 was used to identify patients undergoing arthroscopic partial meniscectomy. Data were analyzed to determine whether patients in this group had a diagnosis of knee OA within 12 months before surgery and for the presence of a new diagnosis of knee OA at 3, 6, and 12 months after APM.

RESULTS

Five lakhs thousand nine hundred twenty-two patients with a mean age of 54.0 ± 8.52 years, with the majority female (52.0%), were included. A total of 197,871 patients underwent APM without a diagnosis of knee OA at the time of the procedure. Of these patients, 109,427 (55.3%) had a previous diagnosis of knee OA within 12 months preceding surgery, and 24,536 (12.4%), 15,596 (7.9%), and 13,301 (6.7%) patients were diagnosed with knee OA at 3, 6, and 12 months after surgery, respectively.

CONCLUSION

Despite evidence against APM in patients with knee OA, more than half of the patients (55.3%) had a previous diagnosis of OA within 12 months of surgery and 27.0% received a new diagnosis of knee OA within one year of surgery. A notable number of patients had a diagnosis of knee OA either before or shortly after APM.

Hidden Unstable Flap Should Be Suspected in Treating Intractable Pain from Medial Meniscus Horizontal Tear

(1) Background: The medial meniscus horizontal tear (MMHT) is known as a lesion that can be treated nonoperatively. However, some patients show persistent pain despite conservative treatments. In arthroscopic surgery for MMHT, surgeons often encounter unexpected unstable flaps, which can explain the intractable pain. This study aimed to determine whether preoperative factors could predict the hidden unstable flaps in MMHT. (2) Materials and Methods: Medical records of 65 patients who underwent arthroscopic partial meniscectomy (APM) for isolated MMHT during 2016–2020 were retrospectively reviewed. APM was indicated when there was no severe chondral degeneration and intractable localized knee pain in the medial compartment did not resolve despite conservative treatments. Unstable flap was confirmed based on arthroscopic images and operation notes. Each of the following preoperative factors were investigated using logistic regression analyses to determine whether they can predict an unstable flap: age, sex, body mass index, lower limb alignment, trauma history, mechanical symptoms, symptom duration, visual analogue scale (VAS), Lysholm score, cartilage wear of the medial compartment, and subchondral bone marrow lesion (BML). (3) Results: Hidden unstable flaps were noted in 45 (69.2%) patients. Based on univariate analyses for each preoperative factor, age, symptom duration, cartilage wear (of the femoral condyle and the tibial plateau), and subchondral BML were included in the multivariate logistic regression analysis. The results showed that symptom duration (p = 0.026, odds ratio = 0.99) and high-grade cartilage wear of the medial femoral condyle (p = 0.017, odds ratio = 0.06) were negatively associated with unstable flaps. A receiver operating characteristic curve was used to calculate the symptom duration at which the prediction of unstable flaps was maximized, and the cutoff point was 14.0 months. (4) Conclusions: More than two thirds of patients suffering intractable pain from MMHT had hidden unstable flaps. However, APM should not be considered when the symptom duration is more than 14 months or high-grade cartilage wear of the medial femoral condyle is noted.

Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial

Objectives

To assess the long-term effects of arthroscopic partial meniscectomy (APM) on the development of radiographic knee osteoarthritis, and on knee symptoms and function, at 5 years follow-up.

Design

Multicentre, randomised, participant- and outcome assessor-blinded, placebo-surgery controlled trial.

Setting

Orthopaedic departments in five public hospitals in Finland.

Participants

146 adults, mean age 52 years (range 35–65 years), with knee symptoms consistent with degenerative medial meniscus tear verified by MRI scan and arthroscopically, and no clinical signs of knee osteoarthritis were randomised.

Interventions

APM or placebo surgery (diagnostic knee arthroscopy).

Main outcome measures

We used two indices of radiographic knee osteoarthritis (increase in Kellgren and Lawrence grade ≥1, and increase in Osteoarthritis Research Society International (OARSI) atlas radiographic joint space narrowing and osteophyte sum score, respectively), and three validated patient-relevant measures of knee symptoms and function (Western Ontario Meniscal Evaluation Tool (WOMET), Lysholm, and knee pain after exercise using a numerical rating scale).

Results

There was a consistent, slightly greater risk for progression of radiographic knee osteoarthritis in the APM group as compared with the placebo surgery group (adjusted absolute risk difference in increase in Kellgren-Lawrence grade ≥1 of 13%, 95% CI −2% to 28%; adjusted absolute mean difference in OARSI sum score 0.7, 95% CI 0.1 to 1.3). There were no relevant between-group differences in the three patient-reported outcomes: adjusted absolute mean differences (APM vs placebo surgery), −1.7 (95% CI −7.7 to 4.3) in WOMET, −2.1 (95% CI −6.8 to 2.6) in Lysholm knee score, and −0.04 (95% CI −0.81 to 0.72) in knee pain after exercise, respectively. The corresponding adjusted absolute risk difference in the presence of mechanical symptoms was 18% (95% CI 5% to 31%); there were more symptoms reported in the APM group. All other secondary outcomes comparisons were similar.

Conclusions

APM was associated with a slightly increased risk of developing radiographic knee osteoarthritis and no concomitant benefit in patient-relevant outcomes, at 5 years after surgery.

Trial registration

ClinicalTrials.gov (NCT01052233 and NCT00549172).

Arthroscopic meniscectomy versus non-surgical or sham treatment in patients with MRI confirmed degenerative meniscus lesions: a protocol for an individual participant data meta-analysis

INTRODUCTION

Arthroscopic partial meniscectomy (APM) after degenerative meniscus tears is one of the most frequently performed surgeries in orthopaedics. Although several randomised controlled trials (RCTs) have been published that showed no clear benefit compared with sham treatment or non-surgical treatment, the incidence of APM remains high. The common perception by most orthopaedic surgeons is that there are subgroups of patients that do need APM to improve, and they argue that each study sample of the existing trials is not representative for the day-to-day patients in the clinic. Therefore, the objective of this individual participant data meta-analysis (IPDMA) is to assess whether there are subgroups of patients with degenerative meniscus lesions who benefit from APM in comparison with non-surgical or sham treatment.

METHODS AND ANALYSIS

An existing systematic review will be updated to identify all RCTs worldwide that evaluated APM compared with sham treatment or non-surgical treatment in patients with knee symptoms and degenerative meniscus tears. Time and effort will be spent in contacting principal investigators of the original trials and encourage them to collaborate in this project by sharing their trial data. All individual participant data will be validated for missing data, internal data consistency, randomisation integrity and censoring patterns. After validation, all datasets will be combined and analysed using a one-staged and two-staged approach. The RCTs' characteristics will be used for the assessment of clinical homogeneity and generalisability of the findings. The most important outcome will be the difference between APM and control groups in knee pain, function and quality of life 2 years after the intervention. Other outcomes of interest will include the difference in adverse events and mental health.

ETHICS AND DISSEMINATION

All trial data will be anonymised before it is shared with the authors. The data will be encrypted and stored on a secure server located in the Netherlands. No major ethical concerns remain. This IPDMA will provide the evidence base to update and tailor diagnostic and treatment protocols as well as (international) guidelines for patients for whom orthopaedic surgeons consider APM. The results will be submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017067240.

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 5-Year Follow-up of a Prospective, Randomized Study

Background:

Arthroscopic meniscal surgery is a common orthopaedic procedure in middle-aged patients, but the efficacy of this procedure has been questioned. In this study, we followed up the only randomized controlled trial that has shown a 1-year benefit from knee arthroscopic surgery with an exercise program compared with an exercise program alone.

Purpose:

To (1) evaluate whether knee arthroscopic surgery combined with an exercise program provided an additional 5-year benefit compared with an exercise program alone in middle-aged patients with meniscal symptoms, (2) determine whether baseline mechanical symptoms affected the outcome, and (3) compare radiographic changes between treatment groups.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Of 179 eligible patients aged 45 to 64 years, 150 were randomized to either a 3-month exercise program (nonsurgery group) or to the same exercise program plus knee arthroscopic surgery (surgery group) within 4 weeks. Radiographs were assessed, according to the Kellgren-Lawrence grade, at baseline and at the 5-year follow-up. The primary outcome was the change in Knee injury and Osteoarthritis Outcome Score (KOOS)–Pain (KOOS_PAIN) subscore from baseline to the 5-year follow-up. We performed an as-treated analysis.

Results:

A total of 102 patients completed the 5-year questionnaire. At the 5-year follow-up, both groups had significant improvement in KOOS_PAIN subscores, although there was no significant change from the 3-year scores. There was no between-group difference in the change in the KOOS_PAIN subscore from baseline to 5 years (3.2 points [95% CI, –6.1 to 12.4]; adjusted P = .403). In the surgery group, improvement was greater in patients without mechanical symptoms than in those with mechanical symptoms (mean difference, 18.4 points [95% CI, 8.7 to 28.1]; P < .001). Radiographic deterioration occurred in 60% of patients in the surgery group and 37% of those in the nonsurgery group (P = .060).

Conclusion:

Knee arthroscopic surgery combined with an exercise program provided no additional long-term benefit after 5 years compared with the exercise program alone in middle-aged patients with meniscal symptoms. Surgical outcomes were better in patients without mechanical symptoms than in patients with mechanical symptoms during the preoperative period. Radiographic changes did not differ between treatment groups.

Registration:

NCT01288768 (ClinicalTrials.gov identifier).

Wild goose chase - no predictable patient subgroups benefit from meniscal surgery: patient-reported outcomes of 641 patients 1 year after surgery

BACKGROUND

Despite absence of evidence of a clinical benefit of arthroscopic partial meniscectomy (APM), many surgeons claim that subgroups of patients benefit from APM.

OBJECTIVE

We developed a prognostic model predicting change in patient-reported outcome 1 year following arthroscopic meniscal surgery to identify such subgroups.

METHODS

We included 641 patients (age 48.7 years (SD 13), 56% men) undergoing arthroscopic meniscal surgery from the Knee Arthroscopy Cohort Southern Denmark. 18 preoperative factors identified from literature and/or orthopaedic surgeons (patient demographics, medical history, symptom onset and duration, knee-related symptoms, etc) were combined in a multivariable linear regression model. The outcome was change in Knee injury and Osteoarthritis Outcome Score (KOOS₄) (average score of 4 of 5 KOOS subscales excluding the activities of daily living subscale) from presurgery to 52 weeks after surgery. A positive KOOS₄ change score constitutes improvement. Prognostic performance was assessed using R² statistics and calibration plots and was internally validated by adjusting for optimism using 1000 bootstrap samples.

RESULTS

Patients improved on average 18.6 (SD 19.7, range -38.0 to 87.8) in KOOS₄. The strongest prognostic factors for improvement were (1) no previous meniscal surgery on index knee and (2) more severe preoperative knee-related symptoms. The model's overall predictive performance was low (apparent R²=0.162, optimism adjusted R²=0.080) and it showed poor calibration (calibration-in-the-large=0.205, calibration slope=0.772).

CONCLUSION

Despite combining a large number of preoperative factors presumed clinically relevant, change in patient-reported outcome 1 year following meniscal surgery was not predictable. This essentially quashes the existence of 'subgroups' with certain characteristics having a particularly favourable outcome after meniscal surgery.

TRIAL REGISTRATION NUMBER

NCT01871272.

Are Orthopaedic Surgeons Performing Fewer Arthroscopic Partial Meniscectomies in Patients Greater Than 50 Years Old? A National Database Study

PURPOSE

To report the trends in arthroscopic partial meniscectomy (APM) for degenerative meniscal tears in a large private insurance database among patients older than 50 years.

METHODS

The Humana database between 2007 and 2015 was queried for this study. Patients meeting the inclusion criteria with degenerative meniscal tears who underwent APMs were identified by International Classification of Diseases, Ninth Revision codes, followed by Current Procedural Terminology codes. A linear regression analysis was performed with a significance level set at F < 0.05.

RESULTS

A total of 21,759 APMs were performed between 2007 and 2015 in patients older than 50 years. Normalized data for total yearly enrollment showed a significant increase in APMs performed from 2007 to 2010 (R² = 0.986, P = .007). The average percentage increase per year from 2007 to 2010 was 18.59%. However, there was a significant decrease in APMs performed from 2010 to 2015 (R² = 0.748, P = .026). The average percentage decrease per year from 2010 to 2015 was 7.74%. The percentage decrease overall from 2010 to 2015 was 71.68%. No difference in statistical significance was found when age was broken into 5-year age intervals. We found a significant difference in APM based on region (P < .001).

CONCLUSIONS

The rate of APMs in patients older than 50 years increased from 2007 until 2010. Since 2010, the rate of APMs in patients older than 50 years has significantly decreased. These trends are likely multifactorial. Regardless of cause, it appears that the orthopaedic surgery community is performing fewer APMs in this patient population.

LEVEL OF EVIDENCE

Level III, retrospective database epidemiological study.

Arthroscopic debridement of the degenerative knee - Is there still a role?

Objectives

The role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee.

Methods

We performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire.

Results

Excellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2-8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results.

Conclusion

Arthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.

Arthroscopic meniscal surgery versus conservative management in patients aged 40 years and older: a meta-analysis

INTRODUCTION

The efficacy of arthroscopic meniscus surgery in old aged patients remains controversial. The purpose of the present study was to review published studies comparing arthroscopic meniscal surgery with conservative management to treat meniscal injuries in patients 40 years of age and older.

MATERIALS AND METHODS

Several electronic databases were queried for articles published until July 2017 that evaluated outcomes of arthroscopic meniscal surgery in patients aged 40 years and older. Data searches, extraction, analysis, and quality assessment were performed according to the Cochrane Collaboration guidelines, and the clinical outcomes were evaluated using various outcome values. The results are presented as the standard mean difference (SMD) for continuous outcomes with 95% confidence intervals (CIs).

RESULTS

Nine randomized controlled trials (RCTs) were included. There were no significant differences in clinical outcomes such as relief in knee pain (SMD = 0.01, 95% CIs = - 0.15 to 0.18, I² = 38%) and improved knee function (SMD = 0.01, 95% CIs = - 0.19 to 0.21, I² = 57%) between arthroscopic meniscal surgery and conservative management for degenerative meniscal tears.

CONCLUSIONS

The efficacy of arthroscopic surgery was not superior to conservative management in this type of patients. Therefore, arthroscopic meniscal surgery should not be recommended as a first choice of treatment for degenerative meniscal tears. In patients over 40 years of age, arthroscopic surgery should be cautiously considered for degenerative meniscal tears and only when there has not been a satisfactory response to conservative management.

Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial

OBJECTIVE

To assess the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy, a placebo surgical intervention, and with a non-operative alternative, exercise therapy, in a more pragmatic setting.

DESIGN

Multicentre, three group, randomised, double blind, sham controlled trial.

SETTING

Orthopaedic departments at three public hospitals in Finland.

PARTICIPANTS

210 patients with symptoms consistent with shoulder impingement syndrome, enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015.

INTERVENTIONS

ASD, diagnostic arthroscopy (placebo control), and exercise therapy.

MAIN OUTCOME MEASURES

Shoulder pain at rest and on arm activity (visual analogue scale (VAS) from 0 to 100, with 0 denoting no pain), at 24 months. The threshold for minimal clinically important difference was set at 15.

RESULTS

In the primary intention to treat analysis (ASD versus diagnostic arthroscopy), no clinically relevant between group differences were seen in the two primary outcomes at 24 months (mean change for ASD 36.0 at rest and 55.4 on activity; for diagnostic arthroscopy 31.4 at rest and 47.5 on activity). The observed mean difference between groups (ASD minus diagnostic arthroscopy) in pain VAS were -4.6 (95% confidence interval -11.3 to 2.1) points (P=0.18) at rest and -9.0 (-18.1 to 0.2) points (P=0.054) on arm activity. No between group differences were seen between the ASD and diagnostic arthroscopy groups in the secondary outcomes or adverse events. In the secondary comparison (ASD versus exercise therapy), statistically significant differences were found in favour of ASD in the two primary outcomes at 24 months in both VAS at rest (-7.5, -14.0 to -1.0, points; P=0.023) and VAS on arm activity (-12.0, -20.9 to -3.2, points; P=0.008), but the mean differences between groups did not exceed the pre-specified minimal clinically important difference. Of note, this ASD versus exercise therapy comparison is not only confounded by lack of blinding but also likely to be biased in favour of ASD owing to the selective removal of patients with likely poor outcome from the ASD group, without comparable exclusions from the exercise therapy group.

CONCLUSIONS

In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00428870.

Patient-reported symptoms and changes up to 1 year after meniscal surgery

Background and purpose - Detailed information on the symptoms and limitations that patients with meniscal tears experience is lacking. This study was undertaken to map the most prevalent self-reported symptoms and functional limitations among patients undergoing arthroscopic meniscal surgery and investigate which symptoms and limitations had improved most at 1 year after surgery. Patients and methods - Patients aged 18-76 years from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing arthroscopic meniscal surgery were included in this analysis of individual subscale items from the Knee Injury and Osteoarthritis Outcome Score and 1 question on knee stability. Severity of each item was scored as none, mild, moderate, severe, or extreme. Improvements were evaluated using Wilcoxon's signed-rank test and effect size (ES). Results - The most common symptoms were knee grinding and clicking, knee pain in general, pain when twisting and bending the knee and climbing stairs (88-98%), while the most common functional limitations were difficulty bending to the floor, squatting, twisting, kneeling, and knee awareness (97-99%). Knee pain in general and knee awareness improved most 1 year after meniscal surgery (ES -0.47 and -0.45; p < 0.001), while knee instability and general knee difficulties improved least (ES 0.10 and -0.08; p < 0.006). Interpretation - Adults undergoing surgery for a meniscal tear commonly report clinical symptoms and functional limitations related to their daily activities. Moderate improvements were observed in some symptoms and functional limitations and small to no improvement in others at 1 year after surgery. These findings can assist the clinical discussion of symptoms, treatments, and patients' expectations.

Comparison of Arthroscopic and Conservative Treatments for Knee Osteoarthritis: A 5-Year Retrospective Comparative Study

PURPOSE

To compare the effectiveness of arthroscopic and conservative treatments in patients with knee osteoarthritis (KOA) with 5 years of follow-up.

METHODS

Patients diagnosed with Kellgren-Lawrence grade 2 to 4 KOA who underwent arthroscopic or conservative treatment from May 2005 to May 2012 were included. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score was collected 1, 2, 3, 4, and 5 years after the initial treatment, and the number of patients who underwent total knee arthroplasty (TKA) at every time point was recorded.

RESULTS

Three hundred eighty-two patients (168 in the conservative group and 214 in the arthroscopy group) were included. Five years after the initial treatment, 32 of the 214 patients who underwent arthroscopy (15.0%) compared with 30 of the 168 patients in the conservative treatment group (17.9%) ultimately underwent TKA, with no statistically significant difference between groups (P = .20). The WOMAC score was significantly lower in the arthroscopy group than in the conservative group at year 1 (24.33 ± 21.56 vs 36.43 ± 16.22, respectively) and year 2 (26.31 ± 17.84 vs 35.41 ± 19.21, respectively). There were no significant between-group differences at years 3, 4, and 5.

CONCLUSIONS

Compared with conservative treatment, arthroscopy provided no benefit in decreasing or delaying arthroplasty surgery. However, arthroscopy had a greater ability to relieve symptoms at 1 and 2 years. Our results suggest that arthroscopy can relieve symptoms up to 2 years without elevating the risk of arthroplasty.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Better outcome from arthroscopic partial meniscectomy than skin incisions only? A sham-controlled randomised trial in patients aged 35-55 years with knee pain and an MRI-verified meniscal tear

OBJECTIVE

Compare arthroscopic partial meniscectomy to a true sham intervention.

METHODS

Sham-controlled superiority trial performed in three county hospitals in Denmark comparing arthroscopic partial meniscectomy to skin incisions only in patients aged 35-55 years with persistent knee pain and an MRI-confirmed medial meniscus lesion. A computer-generated table of random numbers generated two comparison groups. Participants and outcome assessors were blinded to group allocation. Exclusions were locking knees, high-energy trauma or severe osteoarthritis. Outcomes were collected at baseline, 3 and 24 months. We hypothesised no difference between groups. The primary outcome was the between-group difference in change from baseline to 2 years in the mean score across all five normalised Knee injury and Osteoarthritis Outcome Score (KOOS) subscales (KOOS5).

RESULTS

Forty-four patients (of the estimated 72) underwent randomisation; 22 in each group. Sixteen participants (36%) were non-blinded and eight participants (36%) from the sham group crossed over to the surgery group prior to the 2-year follow-up. At 2 years, both groups reported clinically relevant improvements (surgery 21.8, skin incisions only 13.6), the mean difference between groups was 8.2 in favour of surgery, which is slightly less than the cut-off of 10 prespecified to represent a clinically relevant difference; judged by the 95% CI (-3.4 to 19.8), a possibility of clinically relevant difference could not be excluded. In total, nine participants experienced 11 adverse events; six in the surgery group and three in the skin-incisions-only group.

CONCLUSION

We found greater improvement from arthroscopic partial meniscectomy compared with skin incisions only at 2 years, with the statistical uncertainty of the between-group difference including what could be considered clinically relevant. Because of the study being underpowered, nearly half in the sham group being non-blinded and one-third crossing over to surgery, the results cannot be generalised to the greater patient population.

TRIAL REGISTRATION NUMBER

NCT01264991.

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial

OBJECTIVE

To assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus.

METHODS

In this multicentre, randomised, participant-blinded and outcome assessor-blinded, placebo-surgery controlled trial, 146 adults, aged 35-65 years, with knee symptoms consistent with degenerative medial meniscus tear and no knee osteoarthritis were randomised to APM or placebo surgery. The primary outcome was the between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool (WOMET) and Lysholm knee scores and knee pain after exercise at 24 months after surgery. Secondary outcomes included the frequency of unblinding of the treatment-group allocation, participants' satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination. Two subgroup analyses, assessing the outcome on those with mechanical symptoms and those with unstable meniscus tears, were also carried out.

RESULTS

In the intention-to-treat analysis, there were no significant between-group differences in the mean changes from baseline to 24 months in WOMET score: 27.3 in the APM group as compared with 31.6 in the placebo-surgery group (between-group difference, -4.3; 95% CI, -11.3 to 2.6); Lysholm knee score: 23.1 and 26.3, respectively (-3.2; -8.9 to 2.4) or knee pain after exercise, 3.5 and 3.9, respectively (-0.4; -1.3 to 0.5). There were no statistically significant differences between the two groups in any of the secondary outcomes or within the analysed subgroups.

CONCLUSIONS

In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.

Arthroscopic meniscectomy for degenerative meniscal tears reduces knee pain but is not cost-effective in a routine health care setting: a multi-center longitudinal observational study using data from the osteoarthritis initiative

OBJECTIVES

It is disputed whether arthroscopic meniscectomy is an (cost-) effective treatment for degenerative meniscus tears in day-to-day clinical practice. The objective of this study was to assess the cost-effectiveness of arthroscopic meniscectomy in subjects with knee osteoarthritis, in routine clinical practice, while taking into account the increased risk for future knee replacement surgery. We compared cost-effectiveness of arthroscopic meniscectomy compared to no surgery.

DESIGN

We used a state transition (Markov) simulation model to evaluate the cost-effectiveness of arthroscopic meniscectomy compared to no surgery in subjects with knee osteoarthritis (age range 45-79 years). Data used in the preparation of the current study were obtained from the Osteoarthritis Initiative (AOI) database. We applied a 9 years' time horizon (which is equal to the current OAI study follow up period), and evaluated cost-effectiveness from a societal perspective. The main outcome measure was the incremental cost-effectiveness ratio (Euros per quality adjusted life-year (QALY) gained).

RESULTS

Arthroscopic meniscectomy was associated with 8.09 (SD ± 0.07) QALYs at a cost of € 21,345 (SD ± 841), whereas the no surgery was associated with 8.05 (SD ± 0.07) QALYs at a cost of € 16,284 (SD ± 855). For arthroscopic meniscectomy, the incremental cost per QALY gained was € 150,754.

CONCLUSIONS

In day-to-day clinical practice, arthroscopic meniscectomy in subjects with knee osteoarthritis is associated with € 150,754 per QALY gained, which exceeds the generally accepted willingness to pay (WTP) (range € 20,000-€ 80,000).

Signs of knee osteoarthritis common in 620 patients undergoing arthroscopic surgery for meniscal tear

Background and purpose - Recent evidence has questioned the effect of arthroscopic knee surgery for middle-aged and older patients with degenerative meniscal tears with or without concomitant radiographic knee osteoarthritis (OA). We investigated the prevalence of early or more established knee OA and patients' characteristics in a cohort of patients undergoing arthroscopic surgery for a meniscal tear. Patients and methods - 641 patients assigned for arthroscopy on suspicion of meniscus tear were consecutively recruited from February 2013 through January 2015. Of these, 620 patients (mean age 49 (18-77) years, 57% men) with full datasets available were included in the present study. Prior to surgery, patients completed questionnaires regarding onset of symptoms, duration of symptoms, and mechanical symptoms along with the knee injury and osteoarthritis outcome score (KOOS). At arthroscopy, the operating surgeon recorded information about meniscal pathology and cartilage damage. Early or more established knee OA was defined as the combination of self-reported frequent knee pain, cartilage damage, and the presence of degenerative meniscal tissue. Results - 43% of patients (269 of 620) had early or more established knee OA. Of these, a large proportion had severe cartilage lesions with almost half having a severe cartilage lesion in at least 1 knee compartment. Interpretation - Based on a definition including frequent knee pain, cartilage damage, and degenerative meniscal tissue, early or more established knee OA was present in 43% of patients undergoing knee arthroscopy for meniscal tear.

The role for arthroscopic partial meniscectomy in knees with degenerative changes: a systematic review

AIMS

Patients with osteoarthritis of the knee commonly have degenerative meniscal tears. Arthroscopic meniscectomy is frequently performed, although the benefits are debatable. Recent studies have concluded that there is no role for arthroscopic washout in osteoarthritis of the knee. Our aim was to perform a systematic review to assess the evidence for the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee.

PATIENTS AND METHODS

A literature search was performed, using the PubMed/MEDLINE database, for relevant articles published between 1975 and 2015. A total of six studies, including five randomised controlled trials and one cross-sectional study of a prospective cohort, met the inclusion criteria. Relevant information including study design, operations, the characteristics of the patients, outcomes, adverse events and further operations were extracted.

RESULTS

The degree of osteoarthritis in the patients who were included and the rate of cross over from one form of treatment to another varied in the studies. Two randomised controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. One cross-sectional study showed that patients with less severe degenerative changes had better outcomes.

CONCLUSION

Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis. Cite this article: Bone Joint J 2016;98-B:934-8.

A Special Tear Pattern of Anterior Horn of the Lateral Meniscus: Macerated Tear

BACKGROUND

We describe a special, interesting phenomenon found in the anterior horn of the lateral meniscus (AHLM): most tear patterns in the AHLM are distinctive, with loose fibers in injured region and circumferential fiber bundles were separated. We name it as macerated tear. The goal of this study was to bring forward a new type of meniscal tear in the AHLM and investigate its clinical value.

MATERIALS AND METHODS

AHLM tears underwent arthroscopic surgery from January 2012 to December 2014 were included. Data regarding the integrity of AHLM were prospectively recorded in a data registry. Tear morphology and treatment received were subsequently extracted by 2 independent reviewers from operative notes and arthroscopic surgical photos.

RESULTS

A total of 60 AHLM tears in 60 patients (mean age 27.1 years) were grouped into horizontal tears (n = 15, 25%), vertical tears (n = 14, 23%), complex tears (n = 6, 10%), and macerated tears (n = 25, 42%). There were 6 patients with AHLM cysts in macerated tear group and one patient in vertical tear group. 60 patients were performed arthroscopic meniscus repairs and were followed-up with averaged 18.7 months. Each group had significant postoperative improvement in Lysholm and IKDC scores (p < 0.05). However, the macerated tear group showed least functional recovery of Lysholm and IKDC scores compared to other groups (p < 0.05). In addition, there were no differences in postoperative range of motion, return to work, or return to sport/other baseline activities between the four groups (p > 0.05).

CONCLUSIONS

This study demonstrated that the macerated tear is common in the tear pattern of AHLM. However, feasibility of the treatment of this type of meniscal tear, especially the meniscus repairs still requires further study.

Comparison of the recurrence risk of parameniscal cysts between patients treated with arthroscopic excision and arthroscopic decompression techniques

PURPOSE

To compare the recurrence risk of parameniscal cysts between arthroscopic meniscectomy with open cystectomy (arthroscopic excision) and entirely arthroscopic techniques with intra-articular cyst decompression (arthroscopic decompression).

METHODS

A retrospective longitudinal study was conducted at a medical centre in Taiwan between 2002 and 2012. Patients with symptomatic parameniscal cysts undergoing either arthroscopic excision or arthroscopic decompression were included. Parameniscal cyst recurrence was evaluated every 3 months after surgery. The recurrence risk associated with treatment group, cyst volume, and meniscal tear circumference was investigated.

RESULTS

This study included 241 young to middle-aged men and women. Of these, 112 underwent arthroscopic excision and 129 underwent arthroscopic decompression. During an average 26-month follow-up period, the arthroscopic decompression group had a sixfold higher recurrence risk [prevalence: 4 and 21 %, respectively; hazard ratio, HR 6.0 (95 % confidence interval, CI 2.3-15.6); p < 0.001] than the arthroscopic excision group. Furthermore, meniscal tears >12 mm in circumference and a cyst volume >2.4 cm(3) conferred a fivefold higher recurrence risk than both lesions of smaller dimensions, both in the overall population and in the arthroscopic decompression group [HRs 5.3 (95 % CI 2.3-12.2) and 5.35 (95 % CI 2.2-13.3), respectively; p values <0.001 for both].

CONCLUSIONS

The suggestion of our study is that the recurrence of parameniscal cysts may be strongly related to large cystic lesions and large meniscal tears. Arthroscopic excision is preferable for treating parameniscal cysts, which are large cystic lesions with large meniscal tears, to reduce the recurrence risk.

LEVEL OF EVIDENCE

III.

Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms

OBJECTIVE

To determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease.

DESIGN

Systematic review and meta-analysis.

MAIN OUTCOME MEASURES

Pain and physical function.

DATA SOURCES

Systematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed.

RESULTS

The search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0-100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, -0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death.

CONCLUSIONS

The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009145.

A radiopaque electrospun scaffold for engineering fibrous musculoskeletal tissues: Scaffold characterization and in vivo applications

Tissue engineering strategies have emerged in response to the growing prevalence of chronic musculoskeletal conditions, with many of these regenerative methods currently being evaluated in translational animal models. Engineered replacements for fibrous tissues such as the meniscus, annulus fibrosus, tendons, and ligaments are subjected to challenging physiologic loads, and are difficult to track in vivo using standard techniques. The diagnosis and treatment of musculoskeletal conditions depends heavily on radiographic assessment, and a number of currently available implants utilize radiopaque markers to facilitate in vivo imaging. In this study, we developed a nanofibrous scaffold in which individual fibers included radiopaque nanoparticles. Inclusion of radiopaque particles increased the tensile modulus of the scaffold and imparted radiation attenuation within the range of cortical bone. When scaffolds were seeded with bovine mesenchymal stem cells in vitro, there was no change in cell proliferation and no evidence of promiscuous conversion to an osteogenic phenotype. Scaffolds were implanted ex vivo in a model of a meniscal tear in a bovine joint and in vivo in a model of total disc replacement in the rat coccygeal spine (tail), and were visualized via fluoroscopy and microcomputed tomography. In the disc replacement model, histological analysis at 4 weeks showed that the scaffold was biocompatible and supported the deposition of fibrous tissue in vivo. Nanofibrous scaffolds that include radiopaque nanoparticles provide a biocompatible template with sufficient radiopacity for in vivo visualization in both small and large animal models. This radiopacity may facilitate image-guided implantation and non-invasive long-term evaluation of scaffold location and performance.

STATEMENT OF SIGNIFICANCE

The healing capacity of fibrous musculoskeletal tissues is limited, and injury or degeneration of these tissues compromises the standard of living of millions in the US. Tissue engineering repair strategies for the intervertebral disc, meniscus, tendon and ligament have progressed from in vitro to in vivo evaluation using a variety of animal models, and the clinical application of these technologies is imminent. The composition of most scaffold materials however does not allow for visualization by methods available to clinicians (e.g., radiography), and thus it is not possible to assess their performance in situ. In this work, we describe a radiopaque nanofibrous scaffold that can be visualized radiographically in both small and large animal models and serve as a framework for the development of an engineered fibrous tissue.

Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms

OBJECTIVE

To determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease.

DESIGN

Systematic review and meta-analysis.

MAIN OUTCOME MEASURES

Pain and physical function.

DATA SOURCES

Systematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed.

RESULTS

The search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0-100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, -0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death.

CONCLUSIONS

The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009145.

Platelet-rich plasma for open meniscal repair in young patients: any benefit?

PURPOSE

Many studies have demonstrated that injection of various growth factors including platelet-derived growth factor could increase meniscal cell activity and stimulate repair. The purpose of this study was to augment repair and promote meniscal healing by the use of platelet-rich plasma (PRP) within horizontal cleavage meniscal tears repaired via an open approach. The hypothesis was that the clinical outcomes and healing process would be improved using this meniscal healing augmentation technique.

METHODS

In this case-control study, 34 consecutive young patients underwent an open meniscal repair to treat symptomatic Grade 2 or Grade 3 horizontal meniscal tears [median age 28 years (13-40)]. The median time between the onset of symptoms and surgery was 11.5 months (6-50). In the first group (17 consecutive patients, Group 1), a standard open meniscal repair was performed. In the second group (17 consecutive patients, Group 2), the same surgical repair was performed, but platelet-rich plasma was introduced into the lesion at the end of the procedure. Clinical outcomes were evaluated using KOOS and IKDC 2000 scores. MRI was performed at 1 year after surgery for objective evaluation.

RESULTS

At a minimum of 24 months postoperatively (mean 32.2 months, 24-40), three patients underwent subsequent meniscectomy (two in Group 1, one in Group 2). The mean KOOS distribution (pain, symptoms, daily activities, sports, quality of life) was 78.4, 86.1, 93.8, 74.4, 74.6 in Group 1, and 93.3, 90.7, 97.1, 88.8, 78.3 in Group 2 (p < 0.05 for pain and sports parameters). MRI revealed five cases with the complete disappearance of any hypersignal within the repaired meniscus in Group 2, and none in Group 1 (p < 0.01).

CONCLUSIONS

Open meniscal repair of horizontal tears extending into the avascular zone was effective at midterm follow-up in young patients. Clinical outcomes were slightly improved by the addition of PRP in this case-control study.

LEVEL OF EVIDENCE

III.